David Fletcher, MD Department of Medicine University of Toronto - PowerPoint PPT Presentation

Complicated cases
Download
1 / 21

  • 54 Views
  • Uploaded on
  • Presentation posted in: General

Complicated cases. David Fletcher, MD Department of Medicine University of Toronto. CASE 1. 54 yr /o man HIV positive 8 yrs ago Tenofovir /FTC/RTV/ Atazanavir x 4 yrs Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/ wt CD4 320 HIV Viral Load<40. CASE 1.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

David Fletcher, MD Department of Medicine University of Toronto

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


David fletcher md department of medicine university of toronto

Complicated cases

David Fletcher, MDDepartment of MedicineUniversity of Toronto


Case 1

CASE 1

  • 54 yr/o man

  • HIV positive 8 yrs ago

    • Tenofovir/FTC/RTV/Atazanavirx 4 yrs

    • Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/wt

    • CD4 320 HIV Viral Load<40


Case 11

CASE 1

  • Genotype 1a Hepatitis C biopsy proven cirrhosis

  • Compensated and clinically stable

    • Previous therapy in 2009 with Peg INF/1200mg RBV daily resulted in a null response by history from the patient


Case 12

CASE 1

Patient is interested in a retrial of therapy for Hepatitis C with the new direct acting antiviral agents

  • Would you offer treatment?

  • Chance of cure?

  • Which 3rd agent would you choose and why?

  • Does patient’s antiretroviral history play a role in 3rd agent choice?

  • Is there a role for a 4 week lead in here regardless of agent chosen and if so…why?


Case 13

CASE 1

It was decided to move forwards with Peg INF/ 1200mg RBV/Telaprevir

  • Is it necessary to change current ARVs?

  • Would it be necessary to change ARVs if Boceprevir was chosen?...to what?


Case 14

CASE 1

Peg INF/1200mg RBV/Telaprevir…no lead in performed

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Would you continue?

  • Are you concerned about the result?

  • When would you do the next HCVRNA?


Case 15

CASE1

It was decided to continue with Peg INF/1200mg RBV/Telaprevir and HCVRNA rechecked

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 6 HCVRNA <12

  • Would you continue?


Case 16

CASE 1

Peg INF/1200mg RBV/Telaprevir

  • Week 0 HB 140

  • Week 2 HB 125

  • Week 4 HB 109

  • Week 6 HB 99…symptomatic

  • How would you manage anemia?


Case 17

CASE 1

Peg INF/600mgRBV/Telaprevir

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 6 HCVRNA <12 HB 99 (symptoms)

  • Week 8 HCVRNA <12 HB 98 (less symptomatic)

  • What would you do?

  • How would you further manage anemia


Case 18

CASE 1

Peg INF/600mg RBV/Telaprevir

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 6 HCVRNA <12

  • Week 8 HCVRNA <12

  • Week 12 HCVRNA detectable but <12 HB 103

  • What would you do?

  • When would you do your next HCVRNA?


Case 19

CASE 1

Peg INF/RBV re-increased to 1200mg

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but <12

  • Week 8 HCVRNA <12

  • Week 12 HCVRNA detectable but <12

  • Week 14 HCVRNA <12 HB 101

  • What would you do?


Case 110

CASE 1

Peg INF/1200mg RBV

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 12 HCVRNA detectable but <12

  • Week 14 HCVRNA <12 HB 101

  • Week 24 HCVRNA <12 HB 105

  • How much longer would you treat?

  • When would you do your next HCVRNA?


Case 111

CASE 1

Peg INF/1200mg RBV

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but <12

  • Week 12 HCVRNA detectable but <12

  • Week 24 HCVRNA <12

  • Week 36 HCVRNA <12

  • Week 48 HCVRNA <12

  • Are we finished therapy?


Case 112

CASE 1

An additional 24 weeks of PEG INF/RBV (for a total of 72 weeks of therapy) was offered to the patient given the existence of cirrhosis and ?slow HCVRNA clearance as evidenced by a detectable HCVRNA at week 4 and 12

Week 12 and 24 HCVRNA post 72 weeks of therapy were undetectable!


Case 2

CASE 2

  • 52 yo man

  • HIV positive 5 yrs ago

    • CAD with previous MI 3 yrs ago/Hypertensive/Hypothyroidism

  • Tenofovir/FTC/Raltegravir x 4 yrs

    • CD4 700 HIV Viral Load<40


Case 21

CASE 2

  • Hypercholesterolemia and Hypertriglyceridemia on combination therapy with Atorvastatin 80mg/day and Fenofibrate 145mg/day

  • Hypertension controlled on Amlodipine 10mg/day

  • Hypothyroidism controlled on 0.125 mg L-Thyroxine


Case 22

CASE 2

  • Genotype 1a chronic hepatitis C

  • Naïve to therapy

  • F2-3/4 scarring

  • Ready to start triple therapy with PEG INF/RBV/Boceprevir

  • Atorvastatin decreased to 40mg/day

  • Baseline HCVRNA 1.66X10E6


Case 23

CASE 2

  • Week 0 HCVRNA 1.66x10E6

  • Week 4 HCVRNA (lead in)2.37x 10E2

  • Week 8 HCVRNA <12

  • At week 10 begins to feel tired/weak/constipated/muscle cramping

  • TSH noted to be 18.91…L-T4 increased to 0.15mg/d in response


Case 24

CASE 2

  • At week 11 notes increasingly prominent myalgias, more predominant post interferon injection but lasting all week long as opposed to a few hrs post injection, along with increasing weakness

  • Hb stable at 105g/l over last few weeks with RBV dose reduction to 600mg/d

  • AST noted to be increasing while ALT has been normalizing over the last few weeks…also increasing swelling of ankles

    • ?Cause…Hepatic Decompensation?


Case 25

CASE 2

  • CK measured at 83,700

  • BP noted to be low at 90/55 and swelling of ankles worsened now to mid calf…no ascites noted clinically

  • Cause?


Case 26

CASE 2

  • Atorvastatin and Fenofibrate discontinued!!!

  • CK fell over the next few weeks as did AST

  • The symptomatic myalgias and weakness improved over the subsequent month

  • Amlodipine discontinued…BP normalized to 130/80 and ankle swelling disappeared over the next month


  • Login